Intraductal papillary or mucinous tumors (IPMT) of the pancreas: report of a case series and review of the literature

OBJECTIVE: Despite a better understanding of these conditions, intraductal papillary or mucinous tumors (IPMT) of the pancreas still present difficulty relating to the predictive factors of malignancy and the risk of relapse after surgical resection. The aim of this study was to report on our experience and to compare it to previously published cases. METHODS: We studied retrospectively 26 patients (mean age 60.3 yr) presenting with IPMT. Of the 26 patients, 19 had surgical resection and seven did not. The main clinical feature was acute pancreatitis occurring in 38% of the patients. Segmental pancreatectomy was performed in all the cases. At pathological assessment of resection margins, tumor resection was considered as complete in 17 cases. Margins exhibited benign mucinous involvement, and resection was considered to be incomplete in one multifocal case and in one case with diffuse spread of the tumor. RESULTS: A total of 11 tumors were benign and five were malignant. Carcinomas were invasive in four cases (two invading the pancreatic parenchyma, one the duodenum, and one the peripancreatic nodes) and in situ in one case. Malignancy was not diagnosed preoperatively except when invasion was evident (duodenal spread). Although main pancreatic duct type and obstructive jaundice appeared as suggestive features for the risk of malignancy, no reliable preoperative predictive factors for malignancy could be identified as regarding to clinical parameters, biological examinations, carcinoembryonic antigen or CA19-9 levels in serum or in pure pancreatic juice, imaging, and cytological methods. Within 40.8 months mean follow-up after surgery (range 2-96 months), three patients (16%), two with malignant and one with benign tumor, had tumor relapse after respectively 7, 27, and 14 months. Margins were positive without malignant features in the two malignant cases and negative in the other case. Tumor relapse was malignant with diffuse spreading in the three cases, and the patients died within 34 months after surgical resection. CONCLUSIONS: Our series and the review of the literature indicate that preoperative indicators of malignancy in IPMT are still lacking. Concerning resection margins, complete tumor resection is usually possible by segmental pancreatectomy. Malignant relapses are not exceptional. Incomplete resection and diffuse or multifocal tumor represent poor prognostic factors. Total pancreatectomy should be considered in such cases.     

Pylorus-preserving total pancreatectomy for an intraductal papillary-mucinous neoplasm of the pancreas

Background/Purpose

Total pancreatectomy (TP) is rarely performed to treat invasive ductal carcinoma of the pancreas, due to the associated markedly impaired quality of life and poor prognosis after the resection. Intraductal papillary-mucinous neoplasm (IPMN) of the pancreas is characterized by extensive intraductal spread and a favorable outcome even when presenting at an invasive stage. We herein reappraise the role of pylorus-preserving total pancreatectomy (PPTP) as a viable alternative pancreatic resection modality for borderline and malignant IPMN.

Methods

A total of five patients with IPMN underwent PPTP and their clinical follow-up data were reviewed.

Results

TP was performed due to recurrent IPMN in the remnant pancreas after distal pancreatectomy in three patients and due to massive involvement of the entire pancreas in the others. All patients were treated by the pylorus-preserving method, while the spleen was also preserved in one patient. The surgical margins were negative and no metastasis to the resected lymph nodes was evident, based on histological examinations. One patient underwent a re-operation due to postoperative intraabdominal bleeding, while another patient required tubedrainage for left pleural effusion. Three of the four patients who underwent PPTP with a splenectomy experienced postoperative gastric ulcer, which were controlled by medication. One patient died due to suicide 16 months after the PPTP. All the others were doing well without recurrence at periods of 62 to 127 months after the PPTP.

Conclusions

PPTP is therefore considered to be indicated as an effective treatment for borderline or malignant IPMN with extensive involvement, when the patient's condition permits, in order to achieve complete resection of the IPMN.     

Outcome after surgical resection of intraductal papillary and mucinous tumors of the pancreas

OBJECTIVE: Treatment of intraductal papillary and mucinous tumors of pancreas (IPMT) usually requires surgery. The objective of this study was to evaluate the risk of recurrence in patients after surgery according to the histological nature of the neoplasm and the type of surgery. METHODS: The outcome of 45 patients who underwent partial pancreatectomy (n = 35) or total pancreatectomy (n = 10) for IPMT was studied according to the nature of the neoplasm (invasive carcinoma or noninvasive neoplasm), type of surgery (partial or total pancreatectomy), and lymph nodes status. RESULTS: The overall 3-yr actuarial survival rate was 83%. Death occurred in seven of 20 (35%) patients with invasive carcinoma and in one of 26 (4%) patients with noninvasive tumors (p<0.05). There were two recurrences in the seven patients with noninvasive neoplasm who underwent partial pancreatectomy with involved resection margins, and none in the 13 patients with disease-free margins. In patients with invasive carcinoma, there was one recurrence after total pancreatectomy, six after partial pancreatectomy with disease-free margins and six after partial pancreatectomy with involved margins. In patients with invasive carcinoma, total pancreatectomy and the absence of lymph nodes involvement were independently associated with a low risk of recurrence. CONCLUSIONS: IPMT may be managed as follows: 1) in patients with noninvasive neoplasms, partial pancreatic resection should be guided by frozen section examination until disease-free margins are obtained; and 2) in patients with invasive carcinoma, total pancreatectomy seems most likely to cure the patient, but should be discussed according to the general status and the age.     

Distal pancreatectomy without splenectomy and with preservation of splenic vessels

BACKGROUND/AIMS: Conventional distal pancreatic resection routinely involves splenectomy. The awareness that spleen removal may lead to postoperative septic and hematological complications motivated the development of spleen-preserving procedures. Successful distal pancreatectomy with splenic conservation has been reported for treatment of benign pancreatic diseases of the distal pancreas. This report presents the results of spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. METHODOLOGY: Ten patients underwent distal pancreatectomy with splenic vessel preservation. In all cases, both splenic vessels were separated from the pancreas towards the spleen after transecting the body of the pancreas. RESULTS: The indications for the procedure were: neuroendocrine pancreatic tumors (n = 4), cystic neoplasm of the pancreas (n = 4) and cystic-papillary pancreatic tumors (n = 2). Four patients developed pancreatic fistulas with spontaneous healing and there was no mortality. CONCLUSIONS: Spleen-preserving distal pancreatectomy with splenic vessel conservation can be safely performed and should be indicated in the surgical management of benign pancreatic diseases of the distal pancreas.     

Intraductal papillary-mucinous tumors of the pancreas: Clinicopathologic features, outcome, and nomenclature. Members of the Pancreas Clinic, and Pancreatic Surgeons of Mayo Clinic

BACKGROUND & AIMS: Intraductal papillary-mucinous tumor (IPMT) of the pancreatic ducts is increasingly recognized. This study investigated if clinical, imaging, or, histological features predicated outcome, formulated a treatment algorithm, and clarified relationships among IPMT, mucinous cystic neoplasms of the pancreas (MCN), and chronic pancreatitis. METHODS: The medical records, radiographs, and pathological specimens of 15 patients with IPMT (dilated main pancreatic duct or branch ducts with mucin overproduction) who were evaluated between October 1983 and January 1994 were reviewed. RESULTS: One patient had hepatic metastases. Fourteen underwent an operation (6 distal pancreatectomy, 4 total pancreatectomy, and 4 pancreaticoduodenectomy); all had dysplastic intraductal epithelium and chronic pancreatitis, whereas 3 had invasive adenocarcinoma. After a median of 25 months, 10 patients were alive; 3 of 4 with malignant and 2 of 11 with benign IPMT died (P < 0.05). Patients with or without carcinoma had similar clinical and radiographic features. A clinical diagnosis of chronic pancreatitis had been made in 9 patients with benign IMPT and in none with malignant IPMT (P < 0.05). CONCLUSIONS: IPMT is a dysplastic and likely precancerous lesion that is frequently diagnosed as chronic pancreatitis and is separate from MCN. Because it is not possible to distinguish noninvasive from invasive IPMT preoperatively, complete surgical excision of the dysplastic process is our treatment of choice whenever appropriate. (Gastroenterology 1996 Jun;110(6):1909-18)     

Clinicopathologic features and outcomes of intraductal papillary-mucinous tumors of the pancreas

BACKGROUND/AIMS: The authors reviewed their experience with resected IPMT (intraductal papillary-mucinous tumor) of the pancreas to clarify the characteristics and prognosis of this neoplasm. METHODOLOGY: Between 1983 and 1998, 30 consecutive patients with IPMT underwent operations at our institution. Their clinicopathological features and postoperative long-term outcomes were analyzed retrospectively. RESULTS: There were 22 males and 8 females, with a mean age of 64 years. Operations performed were duodenum-preserving pancreatic head resection in 12 patients, distal pancreatectomy in 8, segmental pancreatectomy in 6, conventional pancreaticoduodenectomy in 4. Malignancy was found in 10 of 30 (33%). Factors significantly associated with malignancy were tumor size or presence in main pancreatic duct. In 30 resected patients after a mean follow-up of 60 months, tumor recurrence had occurred in 2 cases of invasive carcinoma that infiltrated into the extrapancreatic organ. The overall actuarial 5-year and 10-year survival was 83% and 62%, respectively. CONCLUSIONS: IPMT has a favorable prognosis after adequate resection. Despite slow growth, IPMT has an obvious malignant potential and a poor prognosis when invasive carcinoma has developed. Early recognition and pancreatectomy is the mainstay of treatment for IPMT.     

Surgical treatment for serous cystadenoma of pancreas--segmental pancreatectomy or conventional resection?

BACKGROUND/AIMS: Benign tumors located in the neck or body of the pancreas are usually removed by left pancreatectomy or pancreaticoduodenectomy when enucleation is too risky for possible damage of the main pancreatic duct. But standard pancreatic resection has its potential operative risk and may result in loss of pancreatic parenchyme and cause impairment of pancreatic function. The aim of this study was to compare the results of segmental pancreatectomy, a limited resection of the mid-portion of the pancreas, and traditional extensive pancreatic resection, i.e. distal pancreatectomy or pancreaticoduodencetomy in patients with serous cystadenoma of the pancreas. METHODOLOGY: From January 1989 to February 2002, 19 patients with serous cystadenoma of the pancreas treated with pancreatic resection were reviewed. Among them segmental pancreatectomy was performed in 5 cases, distal pancreatectomy was carried out in 11, pancreaticoduodenectomy in 2 and total pancreatectomy in one patient. RESULTS: Operation time was significantly longer in segmental pancreatectomy than in distal pancreatectomy (P<0.001) and a greater blood loss was also noticed in the conventional resection. There was no operative mortality and the postoperative hospital stays were not different in any group. A higher rate of pancreatic fistula was encountered in segmental pancreatectomy, however all of the fistulas sealed off after conservative treatment. A trend of higher chance of developing postoperative diabetes was noticed in the conventional resection. Except for the patient who underwent total pancreatectomy no patient developed frank steatorrhea during long-term follow-up. CONCLUSIONS: Segmental pancreatectomy is a safe and technically feasible procedure in selected patients with benign pancreatic tumor. This procedure carries a similar surgical risk as that of standard operation, but avoids extensive pancreatic resection which in turn may preserve more pancreatic functions.     

Total pancreatectomy in six patients with intraductal papillary mucinous tumour of the pancreas: the treatment of choice

BackgroundIntraductal papillary mucinous tumours (IPMT) were described as a distinct entity in l982.The extent of surgical resection remains controversial.MethodsSix patients with a diffuse dilatation of the main pancreatic duct were treated with total pancreatectomy for cure of IPMT.ResultsHistological examination showed one IPM adenoma, four IPM non-invasive carcinomas and one IPM invasive carcinoma. In all but one case multifocal extensive intraductal changes were found, affecting either most of the pancreas or the whole organ. All patients survived the operation and remain alive 5–56 months later. Post-pancreatectomy diabetes has been moderately well controlled.DiscussionIPMTs represent a subgroup of pancreatic neoplasms with a favourable prognosis, and the resection should aim at removing all dysplastic foci. In cases with diffuse dilatation of the main pancreatic duct, widespread tumour involvement of the duct system can be expected, so total pancreatectomy should be the operation of choice.     

Medial pancreatectomy

The surgical treatment of benign tumors of the midportion of the pancreas usually consists of enucleation or formal pancreatectomy. To avoid extended pancreatectomy, a limited resection of the neck of the pancreas has been proposed when enucleation is not feasible. Seven published series report a total number of 78 patients treated by this technique. No postoperative mortality was reported. The operative morbidity ranged from 0% to 40%, mainly due to pancreatic fistulas, which mostly healed spontaneously. In the long term no diabetes mellitus and/or exocrine insufficiency was observed. After resection of low-grade malignant tumors, there was no local recurrence. Medial pancreatectomy is a safe method for the treatment of benign or low-grade malignant tumors of the neck of the pancreas.     

Laparoscopic spleen-preserving distal pancreatectomy for pancreatic neoplasms: A retrospective study

AIM: To describe the clinical characteristics, technical procedures, and outcomes of patients undergoing laparoscopic spleen-preserving distal pancreatectomy (LSPDP) for benign and malignant pancreatic neoplasms.METHODS: The clinical data of 38 patients who underwent LSPDP in the Sir Run Run Shaw Hospital between January 2003 and August 2013 were analyzed retrospectively. Surgical techniques for LSPDP included preservation of the splenic artery and vein (Kimura’s technique) and ligation of the splenic pedicle with preservation of the short gastric vessels (Warshaw’s technique).RESULTS: There were no conversions to open surgery in the 38 patients. Splenic vessels were conserved during spleen-preserving pancreatectomy, except in two patients who underwent resection of the splenic vessels and preservation only of the short gastric vessels. The mean operation time was 123.2 ± 52.4 min, the mean intraoperative blood loss was 78.2 ± 39.5 mL, and the mean postoperative hospital stay was 7.6 ± 2.9 d. The overall rate of postoperative complications was 18.4% (7/38), and the rate of clinical pancreatic fistula was 13.2% (5/38). All postoperative complications were treated conservatively. The postoperative pathological diagnoses were 22 cases of benign pancreatic disease and 16 cases of borderline or low-grade malignant lesions. During a median follow-up of 38 mo (range: 5-133 mo), no recurrence was observed.CONCLUSION: LSPDP is a safe, feasible and effective procedure for the treatment of benign and low-grade malignant tumors of the distal pancreas.     

Laparoscopic distal pancreatectomy for pancreatic cystadenomas

BACKGROUND: Cystic neoplasms are an uncommon group among pancreatic tumors. These lesions are seen more frequently in recent surgical practice, probably because of advances in diagnostic and surgical techniques. Total tumor resection provides the best chance of cure and may remove the risk of malignant transformation of the cystadenomas, particularly of the mucinous type. Minimally invasive techniques have been revolutionary and provide clinical evidence of decreased morbidity and comparable efficacy to traditional, open surgery. However, laparoscopic pancreatic resection is not an established treatment for tumors of the pancreas. AIM: The authors present their initial experience with laparoscopic distal pancreatectomy for pancreatic cystadenomas. MATERIAL AND METHODS: Three female patients (mean age, 55 years) underwent laparoscopic pancreatic resection between September 2001 and December 2003. RESULTS: Laparoscopic pancreatic resection was successfully performed in all patients. Operative time varied between 4 and 6 hours. Intraoperative bleeding was minimal. Due to a thick pancreas, the application of vascular endoscopic stapler was difficult in one patient. Two patients presented postoperative pancreatic leakage with spontaneous resolution. CONCLUSIONS: Resection of the pancreas can be safely performed via the laparoscopic approach with all the potential benefits to the patients of minimally invasive surgery.     

Surgical treatment of intraductal papillary-mucinous tumors of the pancreas

BACKGROUND/AIMS: IPMT (Intraductal papillary-mucinous tumor of the pancreas) is increasingly recognized. The aim of this study was to investigate the appropriate surgical treatment for these tumors. METHODOLOGY: Between January 1981 and September 1998, 62 patients with IPMT underwent surgery. We retrospectively examined the clinicopathological features and surgical outcomes of the patients. RESULTS: The types of IPMT were as follows: hyperplasia (20); adenoma (31); and carcinoma, both invasive (5) and noninvasive (6). Lymph node metastasis was found in 36% of the carcinomas. The size of mural nodules was more than 3 mm in all adenoma or carcinoma cases, while the percentage of hyperplasia less than 3 mm was 75%. Intraoperative pancreatoscopy and annular array ultrasonography were very useful, because they detected 10 lesions that could not be found by preoperative examinations, such as computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography. All patients underwent surgical resection, including 10 pancreaticoduodenectomies (Whipple's procedure), 10 pylorus-preserving pancreaticoduodenectomies, 13 pancreatic head resections with segmental duodenectomies, 17 distal pancreatectomies, 9 segmental resections of the pancreas, 2 duodenum-preserving pancreatic head resections, and 1 total pancreatectomy. No operative or hospital death was observed. The postoperative survival rate at 5 years was 71.6% for carcinoma in IPMT. All of the cases with hyperplasia, adenoma and noninvasive carcinoma survived. Only two of the patients with invasive carcinoma died. CONCLUSIONS: IPMT had a favorable prognosis, as compared with pancreatic duct carcinoma. When selecting a surgical procedure for treating these tumors, it is important to confirm the tumor extent, as well as the diagnosis of invasion or noninvasion. In cases with invasion, radical resection is required. On the other hand, organ-function-preserving procedures should be selected for diseases without invasion.     

Extrapancreatic neoplasms occur with unusual frequency in patients with intraductal papillary mucinous tumors of the pancreas

OBJECTIVE: Intraductal papillary mucinous tumor (IPMT) of the pancreas has a favorable prognosis. Non-pancreatic primary neoplasms have potential prognostic significance in patients with IPMT. This study focused on the incidence and characteristics of nonpancreatic neoplasms in IPMT patients. METHODS: Forty-two patients (mean age, 64 yr) with IPMT underwent surgery; 16 had adenoma and 26 adenocarcinoma. Preoperative and postoperative, nonpancreatic neoplasms were investigated. The mean postoperative follow-up period was 4.2 yr (range, 0.2-13 yr). Furthermore, 46 patients with pancreatic ductal adenocarcinoma were analyzed for nonpancreatic neoplasms. RESULTS: Five-year survival rates were 100% for benign and 82% for malignant IPMT. Twenty patients (48%) had nonpancreatic neoplasms, before (n = 11), at (n = 4), and after (n = 10) surgery for IPMT. Fifteen patients (32%) had nonpancreatic malignancies. Nonpancreatic neoplasms included colorectal adenomas (21%) and adenocarcinomas (12%), and gastric carcinomas (10%). One patient died of subsequent bile duct carcinoma. Development of nonpancreatic neoplasms was related to age but not to gender, family history, adjuvant chemotherapy, or IPMT pathology. The incidences of nonpancreatic neoplasms and malignancies were significantly higher in patients with IPMT than in those with pancreatic ductal adenocarcinoma (11% and 7%, respectively). CONCLUSIONS: IPMT is associated with a high incidence of nonpancreatic neoplasms, particularly colorectal neoplasms. In IPMT patients, systemic surveillance may allow early detection of second tumors. In preoperative screening and postoperative follow-up of patients with nonpancreatic neoplasms, the possibility of IPMT should be considered.     

Ductal branch-oriented minimal pancreatectomy: Two cases of successful treatment

Two patients with intraductal papillary-mucinous adenoma of the pancreas were successfully treated by ductal branch-oriented minimal pancreatectomy. We propose this novel less invasive ductal branch-oriented pancreatectomy, as indicated for benign ductal ectasia of the pancreas. The cystically dilated branch duct is identified by intraoperative ultrasonography, intraoperative balloon pancreatography, and injection of indigocarmine into the cyst. The cystically dilated branch is resected from the surrounding pancreas together with minimal removal of the pancreatic parenchyma. The communicating duct and cutting margins are tightly ligated to prevent pancreatic juice leakage and fistula. A drainage tube is placed in the main pancreatic duct whenever possible. Histopathologic examination of the transected branch duct is necessary to check for mucosal extension of dysplastic epithelium. This ductal branch-oriented minimal pancreatectomy is the least invasive pancreatectomy and a suitable operation for branch-type ductal ectasia of the pancreas, which is usually benign.     

Segmental pancreatectomy for mucin-producing pancreatic tumors.

BACKGROUND/AIMS: Segmental pancreatectomy for benign tumors of the neck of the pancreas was reported in 1993. Mucin-producing carcinomas are generally regarded as low-grade malignancies as compared with ductal cell carcinomas of the pancreas. We report herein our experience with a segmental pancreatectomy for mucin-producing pancreatic tumors. METHODOLOGY: Three patients with mucin-producing tumors of the pancreatic body underwent a segmental pancreatectomy. After the pancreatic tumor had been located with intra-operative ultrasonography (US), the medial pancreas centered on the tumor was resected. The margin of the retained pancreas was submitted for histopathologic inspection intra-operatively to prevent retained disease. A conduit for draining the pancreatic juice consisted of a jejunal Roux-en-Y loop between the left and cephalic portions of the pancreas. Histologically, the 3 tumors were identified as a cystadenocarcinoma, an intraductal papillary adenocarcinoma, and a cystadenoma with a focus of borderline malignancy. The functional result was evaluated with oral glucose tolerance and pancreatic function diagnostic (PFD) testing. Pancreatic juice drainage was confirmed using magnetic resonance cholangiopancreatography (MRCP). RESULTS: Neither technical failure nor operative death occurred in any of the patients. The patients have been followed-up for between 33 months and 77 months after surgery and all are disease free. The oral glucose tolerance test and PFD test results were all within the normal range. MRCP showed good pancreatic juice drainage in the 2 patients examined. CONCLUSIONS: Segmental pancreatectomy may be an appropriate surgical procedure for mucin-producing pancreatic tumors, to prolong survival and to preserve endocrine and exocrine function.     

Surgical outcome of pancreatic cancer using radical antegrade modular pancreatosplenectomy procedure

AIM:To evaluate the surgical outcomes following radical antegrade modular pancreatosplenectomy (RAMPS) for pancreatic cancer. METHODS:Twenty-four patients underwent RAMPS with curative intent between January 2005 and June 2009 at the National Cancer Center, South Korea. Clinicopathologic data, including age, sex, operative findings, pathologic results, adjuvant therapy, postop-erative clinical course and follow-up data were retro-spectively collected and analyzed for this study. RESULTS:Twenty-one patients (87.5%) underwent distal pancreatectomy and 3 patients (12.5%) underwent total pancreatectomy using RAMPS. Nine patients (37.5%) underwent combined vessel resection, including 8 superior mesenteric-portal vein resections and 1 celiac axis resection. Two patients (8.3%) underwent combined resection of other organs, including the colon, stomach or duodenum. Negative tangential margins were achieved in 22 patients (91.7%). The mean tumor diameter for all patients was 4.09 ± 2.15 cm. The 2 patients with positive margins had a mean diameter of 7.25 cm. The mean number of retrieved lymph nodes was 20.92 ± 11.24 and the node positivity rate was 70.8%. The median survival of the 24 patients was 18.23 ± 6.02 mo. Patients with negative margins had a median survival of 21.80 ± 5.30 mo and those with positive margins had a median survival of 6.47 mo (P = 0.021). Nine patients (37.5%) had postoperative complications, but there were no postoperative mortalities. Pancreatic fistula occurred in 4 patients (16.7%):2 patients had a grade A fistula and 2 had a grade B fistula. On univariate analysis, histologic grade, positive tangential margin, pancreatic fistula and adjuvant therapy were significant prognostic factors for survival. CONCLUSION:RAMPS is a feasible procedure for achieving negative tangential margins in patients with carcinoma of the body and tail of the pancreas.     

Laparoscopic distal pancreatectomy for solid pseudopapillary neoplasm of the pancreas-report of two cases

Solid pseudopapillary neoplasm of the pancreas is a rare pathologic entity. Although the role of laparoscopy in surgery of the pancreas is still controversial, the feasibility and safety of laparoscopic distal pancreatectomy has been reported with good results. We present two cases of laparoscopic distal pancreatectomy in female patients of incidentally found pancreatic solid pseudopapapillary neoplasm, with review of disease and technical aspect. They underwent laparoscopic distal pancreatectomy with and without preservation of splenic vessels and spleen respectively. We used four trocars with the patients' posture in strict right lateral decubitus. The operating time was 180 and 240 minutes respectively. There were no critical postoperative complications. The postoperative hospital stay was 10 and 7 days respectively. This minimal invasive surgery can be safely applied to benign or low-grade malignant tumor of the pancreas especially in young and female patients.     

Ligamentum teres hepatis patch enhances the healing of pancreatic fistula after distal pancreatectomy

Pancreatic fistula is one of the most common complications after the distal pancreatectomy. Many methods have been tried to solve the problem, but no one is optimal, especially for the soft pancreatic stump cases. This study used ligamentum teres hepatis as a patch to cover the pancreatic stump. Between October 2010 and December 2012, seventy-seven patients who had undergone distal pancreatectomy with a soft pancreatic stump were divided into two groups: group A (n=39, patients received conventional ligated main pancreatic duct method) and group B (n=38, patients underwent a coverage procedure). Patients in group A had a longer recovery from postoperative pancreatic fistula than those in group B (16.4±3.5 vs 10.8±1.6 days, P<0.05). The coverage procedure with ligamentum teres hepatis is a safe, effective and convenient method for patients with a soft pancreas remnant during distal pancreatectomy.     

Laparoscopic distal pancreatectomy for insulinoma with preservation of the spleen

We report on a successful laparoscopic distal pancreatectomy due to insulinoma, preserving the spleen and the splenic vessels in a 29-year-old male patient who presented with repeated syncope due to hypoglycemia. The ultrasound exam did not show the pancreatic lesion; it was only the angiotomography of the pancreas that revealed a 3-cm mass located at the transition from the body to the tail of the pancreas. The laparoscopic distal pancreatectomy was performed using a harmonic scalpel (Ethicon EndoSurgery/UltraCision), without mechanical suturing. There were no intra- or postoperative complications or hypoglycemias during the 6 months of follow-up. When it is performed by experienced laparoscopic surgeons, this is a technically feasible procedure, safe for the treatment of benign lesions of the pancreas body and tail.     

Intraductal papillary mucinous tumors of the pancreas

Cystic neoplasms of the exocrine pancreas are a small fraction of pancreatic tumors. Within that group of cystic neoplasms, intraductal papillary mucinous tumors (IPMTs) can be distinguished from mucinous cystic neoplasms, serous cystic neoplasms, and pseudopapillary cystic tumors. Awareness of IPMTs has increased since the World Health Organization classified these tumors as its own group in 1996. Because of their favorable prognosis, an extensive diagnostic workup for IPMTs should be performed in patients presenting with cystic lesions of the pancreas. This workup often leads to the diagnosis and the predominant tumor location and size, although the extent of the ductal changes can only be established by histopathology. Surgical resection is the therapy of choice for IPMTs. The type of resection depends upon the extent of the quantitative and qualitative ductal involvement. Total pancreatectomy is currently the treatment for an IPMT that comprises the entire main duct.